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Wiki Fetal Demise at 18 weeks

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COG2022

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One of our physicians had a patient deliver at 18 weeks vaginally. This was not an induced labor, the physician was there for the delivery. Everything I am reading online is indicating to bill 59855 if the labor was induced and vaginal delivered however this was not an induced labor. Any guidance will be greatly appreciated.
 
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Hi, by this was not an induced labor, you mean it was spontaneous labor, ie a spontaneous abortion? Can you provide more information about the situation? If the patient came in in labor and delivered, your physician can really only bill E&M codes.

In my state (WI) the law states - Induced termination of pregnancy defined: ‘‘Induced abortion’’ means the termination of a uterine pregnancy by a physician of a woman known by the physician to be pregnant, for a purpose other than to produce a live birth or to remove a dead fetus. (Wisconsin Statutes 69.01 (13m)).

Therefore I would only use induced abortion codes like 59855 is for a termination, ie, the fetus is living and the pregnancy is being terminated due to mother or fetal health. In the ACOG link below, it basically has all the different codes and says - However, some state legislatures have legally defined the difference between a miscarriage and a stillbirth by the number of weeks or by gram weight. This legal definition may determine which CPT codes are selected: abortion (59812-59857) or delivery (59400-59515).

From what I can see, Ohio defines abortion the same way as WI - As used in the Revised Code, "abortion" means the purposeful termination of a human pregnancy by any person, including the pregnant woman herself, with an intention other than to produce a live birth or to remove a dead fetus or embryo. Abortion is the practice of medicine or surgery for the purposes of section 4731.41 of the Revised Code. https://codes.ohio.gov/ohio-revised-code/section-2919.11

 
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Hello,
I am new to OBGYN. I would like to add that in order to even bill for 59855-induced abortion, ACOG advised me that VAGINAL suppositories must be given. From that moment, I pay attention to this criteria. Thank you, Cmama12, for your response!
59855
Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines;
 
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COG2022 said:
One of our physicians had a patient deliver at 18 weeks vaginally. This was not an induced labor, the physician was there for the delivery. Everything I am reading online is indicating to bill 59855 if the labor was induced and vaginal delivered however this was not an induced labor. Any guidance will be greatly appreciated.
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From your statement, it appears this may have been a spontaneous miscarriage (abortion) at 18 weeks. If the physician assisted with this delivery you will bill only an E/M code. Any pregnancy delivery prior to 20 weeks gestation cannot be billed as a delivery (such as 59409). If he did not induce the labor, as you seem to imply, then 59855 would not be correct. This code is intended for inducing, artificially, the termination of a pregnancy.
 
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Would you be able to bill CPT 59414-delivery of placenta in addition to the e/m for spontaneous miscarriage at 19 weeks?
"Patient is a 25 yo G1P0 at 19 5/7 wks who presents to ER with c/o cramping and spotting. Us was done with evidence of cervical insufficiency membranes prolapsing through the cervical os. Patient then had SROM and was admitted to L and D for further observation. No FHTs noted by us on presentation to L and D. Patient progressed to deliver a non viable male infant of Apgars 0 and 0, weight 290 grams, 25 1/2 cm length. femur length 9 cm. She pushed to deliver in footling breech presentation. Legs reduced and delivered followed by arms reduced across the chest. Fetus delivered to the level of the neck and then experienced head entrapment. Cytotec 200 mcg was given and fetal head delivered. Placenta delivered complete after additional dose of 400 mcg of Cytotec. An additional 2 Cytotec were given rectally for hemorrhage prophylaxis. Ther vagina, rectum and cervix were intact. QBL 244"
 
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stale94@sbcglobal.net said:
Would you be able to bill CPT 59414-delivery of placenta in addition to the e/m for spontaneous miscarriage at 19 weeks?
"Patient is a 25 yo G1P0 at 19 5/7 wks who presents to ER with c/o cramping and spotting. Us was done with evidence of cervical insufficiency membranes prolapsing through the cervical os. Patient then had SROM and was admitted to L and D for further observation. No FHTs noted by us on presentation to L and D. Patient progressed to deliver a non viable male infant of Apgars 0 and 0, weight 290 grams, 25 1/2 cm length. femur length 9 cm. She pushed to deliver in footling breech presentation. Legs reduced and delivered followed by arms reduced across the chest. Fetus delivered to the level of the neck and then experienced head entrapment. Cytotec 200 mcg was given and fetal head delivered. Placenta delivered complete after additional dose of 400 mcg of Cytotec. An additional 2 Cytotec were given rectally for hemorrhage prophylaxis. Ther vagina, rectum and cervix were intact. QBL 244"
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In my opinion, no. The placenta delivered normally without physician intervention per your description. But I think you should be looking at higher levels of E/M and possibly prolonged services if time was documented.
 
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It triggered a question to ask and thank you very much to all for participating in this forum! My question is about E/M. Which note do we use for leveling E/M? Do we level H&P or the Delivery/procedural note? I had this question in my head for a long time and now it's a perfect scenario to ask. If a delivery note, then we should ask for Time. Thank you Cmama12 and Nielynco for sharing your expertise with us.
 
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natashalage said:
It triggered a question to ask and thank you very much to all for participating in this forum! My question is about E/M. Which note do we use for leveling E/M? Do we level H&P or the Delivery/procedural note? I had this question in my head for a long time and now it's a perfect scenario to ask. If a delivery note, then we should ask for Time. Thank you Cmama12 and Nielynco for sharing your expertise with us.
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If this were after Jan. 1 2023, H&P would no longer impact your selection of the code for an inpatient hospital service - medical decision making or total time would. But for now I would use both notes to calculate the level of service. You should be able to get the level of medical decision making from the H&P and then any additional exam elements from the delivery note which might support that level of decision making (which would be moderate I would think in the case we were discussing).
 
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